MEDICARE: MR. JOHN JOSEPH LONGMORE JR. PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant

General Provider Information

NPI Number	:	1255535050
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN JOSEPH LONGMORE JR. PTA

Provider Business Mailing Address
First Line	:	415 E CHIPPEWA ST
Second Line	:
City	:	MT PLEASANT
State	:	MI
Zip	:	48858-1613
Country	:	US
Telephone Number	:	989-773-9404
Fax Number	:

Provider Business Practice Location Address
First Line	:	1234 E BROOMFIELD ST
Second Line	:
City	:	MT PLEASANT
State	:	MI
Zip	:	48858-4491
Country	:	US
Telephone Number	:	989-773-1333
Fax Number	:	989-773-1303

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2007
Last Update Date	:	07/08/2007

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